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Europe is watching a perfect storm unfold on its doorstep. Ukraine's fertile black earth, enriched by centuries of manure, is teeming with microbes. To add to this, drones hover above the trenches, preventing swift evacuation of the wounded. This causes wounded soldiers to lie longer in dirt, suffering multiple infections that antibiotics can no longer banish. The result amongst Ukrainian troops is more than troublesome: a surge in amputations, sepsis and deaths.
What is emerging is being described as nothing less than trench warfare in a post-antibiotic era, where hygiene practices are forced back to those of Florence Nightingale in the Crimean War.
This was the warning sounded in London this week at the Lessons From the Frontline conference, held at the Sir Michael Uren Hub, Imperial College's White City campus. Doctors, historians and policymakers spoke of Ukraine as the world's first "post-antibiotic war".
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Scientific data is offering up little in the way of comfort. Ukraine was already battling high antimicrobial resistance (AMR) before 2022. The full scale invasion multiplied the scourge.
And now, with soldiers falling wounded on soil alive with bacteria, their injuries pressed into fields fertilised for centuries, the subsequent infections are proving impossible to treat.
"Ukraine is farmland that has had manure dug into it for hundreds of years," says Emily Mayhew, a medical historian at Imperial College.
It is highly bacterially active, and people fall onto the ground, much as they did on the Western Front. Infected wounds now resemble those of a pre-antibiotic era. I look at Ukraine and I see a post-antibiotic war
Emily Mayhew, medical historian at Imperial College.
Hygiene has also, in parts, collapsed as Ukraine's medical infrastructure has buckled. Hospitals are overcrowded, nurses overstretched, sterilisation crippled by bombardment and power cuts. Transfers of patients scatter microbes across the country.
"The war has amplified this exponentially," says Hailie Uren, an Australian-born consultant for the Ukrainian Ministry of Health. "By the time they reach western Ukraine, many carry six completely resistant bacteria. Around 30% cannot be treated with antibiotics at all."
The pathogens are formidable. Klebsiella pneumoniae, responsible for one in five AMR deaths worldwide, has in Ukraine mutated into strains impervious to every drug.
Eight in ten wounded soldiers now carry the NDM-1 resistance gene, ten times Europe's average. Acinetobacter baumannii, once nicknamed "Iraqibacter," has resurfaced, unbowed even by carbapenems, the last line of defence. Together with Pseudomonas aeruginosa, these form the dreaded "extensively drug-resistant" category.
For patients, the consequences are long-lasting.
Oleksander Bezverkhny, a soldier, lost both legs and endured five bouts of sepsis after treatment in three hospitals. His survival required 100 operations and rare imported drugs. Many others are not so fortunate: mortality rates for such infections can exceed 50%.
Singurgeons are increasingly turning to amputation as the only viable option, with as many as 100,000 amputations estimated amongst the war wounded.
As Dr Danylo Turkevych, a Ukrainian trauma surgeon who works at the Superhumans rehabilitation center in Lviv, Ukraine, says: "If you have a patient treated for six or twelve months and you still have continuous infectious complications, often the only solution is amputation. People get tired, the risk of sepsis grows, and sometimes it is simply easier for the patient to lose the limb an...
